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CATEGORY	DETAILS
Risk Factors	Vitamin D deficiency (poor diet, limited sun exposure, dark skin at high latitudes), chronic kidney disease (CKD), malabsorption syndromes (celiac disease, Crohn disease, gastric bypass), chronic liver disease, prolonged use of anticonvulsants (phenytoin, carbamazepine), renal phosphate wasting (tumor-induced osteomalacia, X-linked hypophosphatemia)
Etiology	Defective mineralization of newly formed osteoid in mature bone, most commonly due to vitamin D deficiency or phosphate depletion
Patient Presentation	Diffuse, dull bone pain (pelvis, spine, ribs, lower extremities), proximal muscle weakness, difficulty rising from a chair or climbing stairs, waddling gait
Classic Physical Exam	Bone tenderness on palpation (sternum, tibia, forearms), proximal myopathy with preserved reflexes, waddling gait, no joint swelling or erythema
Key Diagnostic Results	Low serum 25-hydroxyvitamin D, low serum calcium, low serum phosphate, elevated alkaline phosphatase (ALP), elevated PTH (secondary hyperparathyroidism), Looser zones (pseudofractures) on X-ray, increased unmineralized osteoid on bone biopsy
Management	Vitamin D supplementation (ergocalciferol or cholecalciferol) with calcium; treat underlying cause (e.g., phosphate supplementation in hypophosphatemic forms, managing malabsorption)
Keywords	"Diffuse bone pain," "proximal muscle weakness," "waddling gait," "Looser zones," "pseudofractures," "increased osteoid," "elevated ALP with low calcium and phosphate"

1. Pathophysiology

Osteomalacia is fundamentally a disease of defective mineralization. In healthy bone remodeling, osteoblasts lay down a protein scaffold called osteoid, which is then mineralized by the deposition of calcium and phosphate in the form of hydroxyapatite crystals. For this mineralization to proceed normally, three conditions must be met: adequate serum calcium, adequate serum phosphate, and a proper alkaline environment at the mineralization front. When any of these conditions fails, osteoid accumulates without being mineralized, and the bone becomes soft and structurally weak.

The most common pathway to osteomalacia is vitamin D deficiency. Vitamin D (as its active metabolite, 1,25-dihydroxyvitamin D / calcitriol) promotes intestinal absorption of calcium and phosphate. When vitamin D is deficient, both calcium and phosphate absorption from the gut drops significantly. The resulting hypocalcemia triggers the parathyroid glands to secrete PTH (secondary hyperparathyroidism). PTH works to restore serum calcium by mobilizing calcium from bone and increasing renal calcium reabsorption, but it simultaneously causes renal phosphate wasting through downregulation of sodium-phosphate co-transporters in the proximal tubule. This phosphaturic effect worsens the already low phosphate state, further impairing mineralization. The net result is a $Ca^{2+} \times PO_4^{3-}$ ion product that is too low to support hydroxyapatite crystal formation.

This explains the clinical picture directly. The diffuse bone pain arises because unmineralized osteoid is mechanically weak, allowing microstress and periosteal stretching under normal weight-bearing loads. The proximal muscle weakness results from vitamin D deficiency itself (vitamin D receptors are expressed in skeletal muscle and are required for normal myocyte function) as well as from the associated hypophosphatemia, which depletes intracellular ATP needed for muscle contraction. The characteristic waddling gait is a compensatory pattern for pelvic girdle weakness, and the pseudofractures (Looser zones) represent stress fractures through the soft, undermineralized bone at points where blood vessels enter the cortex, creating mechanical vulnerability.

A second pathway involves primary phosphate deficiency without vitamin D deficiency. This is seen in tumor-induced osteomalacia (oncogenic osteomalacia), where a mesenchymal tumor secretes fibroblast growth factor 23 (FGF-23), which causes renal phosphate wasting and suppresses 1-alpha-hydroxylase activity. In X-linked hypophosphatemia, a genetic mutation leads to overproduction of FGF-23 with the same downstream effects. In these cases, calcium may be normal or near-normal, but the phosphate depletion alone is sufficient to impair mineralization.

A third, less commonly tested pathway involves chronic kidney disease. In CKD, the kidneys lose the ability to convert 25-hydroxyvitamin D to its active form (1,25-dihydroxyvitamin D) due to loss of 1-alpha-hydroxylase activity. Additionally, phosphate retention in CKD further disrupts the calcium-phosphate balance. This form is often grouped under "renal osteodystrophy," which has overlapping features of osteomalacia, osteitis fibrosa cystica, and adynamic bone disease.

2. Classification and Clinical Manifestation

TYPE	MECHANISM	KEY CLINICAL AND LAB FEATURES
Vitamin D Deficiency Osteomalacia	Inadequate intake, malabsorption, or insufficient sunlight leading to low 25(OH)D	Diffuse bone pain, proximal weakness, low calcium, low phosphate, elevated PTH, elevated ALP, low 25(OH)D
Renal Tubular Phosphate Wasting	Renal phosphate loss (Fanconi syndrome, X-linked hypophosphatemia)	Bone pain, rickets-like deformities in children, isolated low phosphate, normal or mildly low calcium, normal 25(OH)D, elevated FGF-23 in hereditary forms
Tumor-Induced (Oncogenic) Osteomalacia	Mesenchymal tumor secreting FGF-23 causing renal phosphate wasting and low calcitriol	Severe bone pain and weakness in an adult, profoundly low phosphate, normal calcium, elevated FGF-23, normal 25(OH)D, symptoms resolve after tumor resection
CKD-Associated Osteomalacia	Loss of 1-alpha-hydroxylase activity in the kidney and phosphate retention	Bone pain, may overlap with osteitis fibrosa cystica, low calcitriol, high phosphate (unlike other forms), high PTH, normal 25(OH)D
Drug-Induced Osteomalacia	Anticonvulsants (phenytoin, carbamazepine) accelerate hepatic catabolism of vitamin D via CYP450 induction	Chronic bone pain in patients on long-term anticonvulsants, low 25(OH)D, otherwise similar to vitamin D deficiency form
Hereditary Vitamin D-Dependent Rickets (adult presentation)	Type I: defective 1-alpha-hydroxylase; Type II: defective vitamin D receptor	Type I: low calcitriol with normal 25(OH)D, responds to calcitriol. Type II: high calcitriol (receptor resistance), may have alopecia, poor response to calcitriol

3. Diagnostic Workup

TEST	ROLE	EXPECTED FINDINGS
Serum 25-hydroxyvitamin D	Best initial test for vitamin D deficiency osteomalacia	Low (< 20 ng/mL confirms deficiency; < 10 ng/mL strongly associated with osteomalacia)
Serum calcium	Part of initial metabolic panel	Low or low-normal
Serum phosphate	Part of initial metabolic panel	Low (often the earliest lab abnormality)
Alkaline phosphatase (ALP)	Reflects osteoblastic activity / impaired mineralization	Elevated (often markedly so)
Intact PTH	Identifies secondary hyperparathyroidism	Elevated
24-hour urine calcium	Assesses calcium balance	Low (due to decreased gut absorption)
X-ray of affected bones	Initial imaging	Looser zones (pseudofractures), generalized osteopenia, cortical thinning
DEXA scan	Measures bone mineral density	Low BMD (but cannot distinguish osteomalacia from osteoporosis alone)
Bone biopsy with tetracycline labeling	Most accurate / confirmatory test (gold standard)	Increased osteoid volume and thickness, widened osteoid seams, decreased or absent tetracycline labeling (indicating impaired mineralization rate)
Serum FGF-23	Ordered when phosphate wasting is suspected without vitamin D deficiency	Elevated in tumor-induced and hereditary hypophosphatemic osteomalacia

The best initial test when osteomalacia is suspected is a serum 25-hydroxyvitamin D level alongside a basic metabolic panel (calcium, phosphate) and ALP. This combination is usually sufficient to establish the diagnosis in the majority of cases. The classic lab constellation is low 25(OH)D, low calcium, low phosphate, elevated ALP, and elevated PTH. This pattern immediately points toward vitamin D deficiency as the driver and distinguishes osteomalacia from conditions like osteoporosis, where these values are typically normal.

X-rays should be obtained of symptomatic areas. The hallmark radiographic finding is the Looser zone, also called a pseudofracture or Milkman fracture. These appear as radiolucent lines running perpendicular to the cortical surface, most commonly in the medial femoral neck, pubic rami, lateral scapular border, and ribs. They represent bands of unmineralized osteoid and are considered pathognomonic for osteomalacia. Generalized osteopenia and blurring of trabecular detail may also be seen but are nondiagnostic.

A DEXA scan will show reduced bone mineral density, but it cannot distinguish osteomalacia from osteoporosis because it measures total mineral content per area rather than assessing mineralization quality. This is an important test-taking distinction: a low DEXA alone does not confirm osteomalacia.

The most accurate test is a transiliac bone biopsy with prior double tetracycline labeling. The patient takes tetracycline at two timed intervals before the biopsy. In normal bone, two distinct fluorescent bands are seen under ultraviolet light, indicating a normal mineralization rate. In osteomalacia, the bands are poorly separated or absent, and histology reveals widened osteoid seams and increased osteoid volume, confirming that new bone matrix is being formed but not mineralized. In practice, bone biopsy is rarely needed when the clinical picture and labs are classic, but it remains the definitive answer when the diagnosis is uncertain or when labs are equivocal (e.g., CKD-associated bone disease with mixed features).

When the lab profile shows isolated hypophosphatemia with normal 25(OH)D and normal or low calcitriol, order a serum FGF-23 level and investigate for tumor-induced osteomalacia. Localizing the offending tumor often requires functional imaging such as octreotide scintigraphy or Ga-68 DOTATATE PET/CT.

4. Management and Treatment

CLINICAL SCENARIO	TREATMENT	DOSE AND DURATION
Vitamin D deficiency (most common)	Ergocalciferol (D2) or Cholecalciferol (D3) + Calcium	Ergocalciferol 50,000 IU orally once weekly for 8 to 12 weeks, then maintenance of 1,000 to 2,000 IU daily. Calcium carbonate or citrate 1,000 to 1,500 mg/day of elemental calcium.
Severe symptomatic hypocalcemia	IV calcium gluconate acutely, then oral replacement	1 to 2 g of 10% calcium gluconate IV over 10 to 20 minutes, with cardiac monitoring; transition to oral once stable
Malabsorption-related	Higher doses of vitamin D (often D3 preferred for better absorption) + treat underlying GI disease	Cholecalciferol 3,000 to 5,000 IU daily or ergocalciferol 50,000 IU two to three times weekly; ensure concurrent treatment of celiac disease, Crohn disease, or other cause
CKD-associated	Calcitriol (active vitamin D) + phosphate binders	Calcitriol 0.25 to 0.5 mcg daily; phosphate binders with meals to normalize serum phosphate
Drug-induced (anticonvulsants)	Prophylactic or therapeutic vitamin D supplementation	Cholecalciferol 1,000 to 4,000 IU daily depending on degree of deficiency; monitor levels
Tumor-induced osteomalacia	Surgical resection of the FGF-23-producing tumor (curative); if unresectable, phosphate and calcitriol supplementation	Phosphate 1 to 3 g/day in divided doses + calcitriol 0.25 to 1 mcg/day; burosumab (anti-FGF-23 antibody) for refractory cases
X-linked hypophosphatemia	Phosphate supplementation + calcitriol; burosumab	Burosumab (anti-FGF-23 monoclonal antibody) is now first-line in many guidelines; dosed subcutaneously every 2 to 4 weeks

Acute Stabilization: If the patient presents with symptomatic hypocalcemia (tetany, perioral numbness, Chvostek or Trousseau sign, QT prolongation), the immediate priority is IV calcium gluconate with telemetry monitoring. This takes precedence over vitamin D replacement because calcitriol takes days to raise serum calcium, while IV calcium works within minutes. Once the patient is hemodynamically stable and the acute symptoms are controlled, transition to oral calcium and begin vitamin D loading.

Long-Term Management: For the most commonly tested form (nutritional vitamin D deficiency), the standard approach is a loading phase of high-dose ergocalciferol (50,000 IU weekly for 8 to 12 weeks) followed by a maintenance phase of daily supplementation (1,000 to 2,000 IU of vitamin D3 daily). Concurrent oral calcium is essential, typically 1,000 to 1,500 mg of elemental calcium daily, divided into doses to maximize absorption. Monitor serum 25(OH)D, calcium, phosphate, and ALP at 3 to 4 month intervals. ALP will often rise initially as remineralization accelerates (indicating healing) before gradually normalizing over months. This transient ALP rise during treatment should not be mistaken for worsening disease.

Contraindications and Cautions: In patients with granulomatous disease (sarcoidosis, tuberculosis), macrophages contain 1-alpha-hydroxylase that converts 25(OH)D to calcitriol in an unregulated fashion. In these patients, vitamin D supplementation can precipitate hypercalcemia. Similarly, in CKD with hyperphosphatemia, giving vitamin D (especially active calcitriol) without controlling phosphate first can worsen vascular calcification by raising the calcium-phosphate product. Always normalize phosphate with binders before starting calcitriol in CKD.

For tumor-induced osteomalacia, the curative treatment is complete surgical resection of the FGF-23-secreting tumor. When the tumor cannot be localized or is unresectable, medical management with phosphate and calcitriol is used as a bridge. Burosumab, a monoclonal antibody against FGF-23, has emerged as an important treatment option for X-linked hypophosphatemia and refractory tumor-induced osteomalacia.

5. Differential Diagnosis and Distractors

DIFFERENTIAL	WHY IT IS SIMILAR	KEY DISCRIMINATOR
Osteoporosis	Both cause low BMD on DEXA, both present with bone pain and fractures	In osteoporosis, bone is normally mineralized but reduced in quantity. Labs (calcium, phosphate, ALP, vitamin D, PTH) are all normal. Osteomalacia shows the classic lab abnormalities (low Ca, low PO4, high ALP, high PTH). Osteoporosis fractures are compression/fragility fractures, not Looser zones.
Primary Hyperparathyroidism	Elevated PTH, bone pain, possible fractures	In primary hyperparathyroidism, calcium is high (not low). Phosphate is low in both, but hypercalcemia is the distinguishing feature. Classic bone lesion is osteitis fibrosa cystica ("brown tumors"), not pseudofractures.
Paget Disease of Bone	Elevated ALP, bone pain, bone deformities	Paget disease has markedly elevated ALP, but calcium and phosphate are normal. Imaging shows thickened, disorganized bone ("cotton wool" skull, bowing of long bones) rather than osteopenia and Looser zones.
Multiple Myeloma	Diffuse bone pain, osteopenia, pathologic fractures	Myeloma shows lytic "punched-out" lesions on skeletal survey (not pseudofractures), elevated total protein, M-spike on serum protein electrophoresis, and Bence Jones proteinuria. ALP is typically normal in myeloma because osteoclasts are activated without a compensatory osteoblastic response.
Fibromyalgia	Diffuse pain, fatigue, difficulty with daily activities	Fibromyalgia has normal labs (normal calcium, phosphate, ALP, vitamin D) and normal imaging. Tender points are at soft tissue sites, not bone. No objective muscle weakness.
Polymyalgia Rheumatica (PMR)	Proximal muscle pain and stiffness, difficulty rising from a chair	PMR has markedly elevated ESR and CRP, normal ALP and calcium, no bone pain on palpation, and responds dramatically to low-dose corticosteroids. Age is typically over 50.
Rickets	Same pathophysiology (defective mineralization from vitamin D or phosphate deficiency)	Rickets is the pediatric form occurring at open growth plates (epiphyseal widening, rachitic rosary, craniotabes, bowing of legs). Osteomalacia is the adult equivalent in mature, fused bone.

6. Traps and High-Yield Pearls

The most common way students lose points on osteomalacia questions is by confusing it with osteoporosis. Both conditions reduce bone mineral density on DEXA, and both can present with bone pain and fractures. The trap is a vignette that gives you a low DEXA result and asks for the diagnosis without providing lab data. Students reflexively choose osteoporosis because it is far more common. However, if the vignette includes any mention of low calcium, low phosphate, elevated ALP, or elevated PTH, the answer is osteomalacia. The core competency being tested is whether you can recognize that a low DEXA does not automatically mean osteoporosis and that you must look at the metabolic profile.

A second trap involves the ALP during treatment. A vignette may show a patient with known osteomalacia who starts vitamin D and calcium, then returns with a rising ALP. Students are tempted to interpret this as treatment failure or a new diagnosis. In reality, a transient rise in ALP reflects accelerated osteoblastic activity as the bone is healing and remineralizing. The correct answer is to continue therapy and monitor.

A third trap involves distinguishing the type of osteomalacia by the lab pattern. If calcium and phosphate are both low with low 25(OH)D, think vitamin D deficiency. If phosphate is disproportionately low with normal 25(OH)D and normal calcium, think phosphate wasting (tumor-induced or hereditary). Students who only memorize the vitamin D deficiency pattern will miss the oncogenic osteomalacia vignette, which often presents as an adult with severe bone pain, profound hypophosphatemia, normal calcium, and an otherwise unremarkable history until a soft tissue tumor is discovered.

Finally, remember that the gold standard for diagnosing osteomalacia is a bone biopsy with tetracycline labeling, not DEXA and not labs alone. While labs and imaging are usually sufficient in clinical practice, vignettes that ask for the "most accurate test" or "confirmatory test" are looking for the bone biopsy answer, not the 25(OH)D level. The 25(OH)D level is the best initial test.

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